prior authorization list - healthx
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Prior Authorization List
1
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
0051T Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy
00740 Anes Upper Gastrointestinal Endoscopic P
00810 Anes Intestinal Endoscopic Procedures
0095T Removal of total disc arthroplasty, anterior approach; each additional interspace
0169T Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s).
0182T HDR Electronic Brachytherhapy Per Fraction
0282T Percutaneous Or Open Implantation Of Neurostimulator Electrode Array(s), Subcutaneous; For Trial
0284T Revision Or Removal Of Pulse Generator Or Electrodes Including Addition Of New Electrodes, When Performed
0295T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, rev
0296T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording)
0297T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report
0298T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation
0359T Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report
0360T Observational behavioral follow- up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient
0361T Observational behavioral follow- up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient
0362T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient
0363T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient
0364T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time
0365T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time
Prior Authorization List
2
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
0367T Group adaptive behavior treatment by protocol, administered by technician, face- to-face with two or more patients; each additional 30 minutes of technician time
0368T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to- face time
0369T Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time
0370T Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)
0371T Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present)
0372T Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to- face with multiple patients
0373T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient
0374T Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in addition to code for primary procedure)
0438T Transperineal placement of biodegradable material, peri- prostatic (via needle), single or multiple, includes image guidance
0439T Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure)
0440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441T Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve
0442T Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
0443T Real time spectral analysis of prostate tissue by fluorescence spectroscopy
0444T Initial placement of a drug- eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
0445T Subsequent placement of a drug- eluting ocular insert under one or more eyelids, including re- training, and removal of existing insert, unilateral or bilateral
0451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)
0452T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal
0453T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters;
Prior Authorization List
3
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
mechano-electrical skin interface
0454T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode
0462T Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day
0463T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day
0464T Visual evoked potential, testing for glaucoma, with interpretation and report
0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication)
11920 Tattoo/Color Defect to 6.0 Sq Cm
11921 Tattooing 6-20 Sq Cm
11922 Tattoo/Color Defect Ea Add 20 Sq Cm
15002 Surgical Preparation or Creation of Recipient Site, T/A/L; 1st 100 Sq Cm or 1% of Body Area of Infants and Children
15003 Surgical Preparation or Creation of Recipient Site, T/A/L; Ea Addl 100 Sq Cm or Ea Addl 1% of Body Area Infant / Child
15004 Surgical Preparation or Creation of Recipient Site, F/S/E/M/N/E/O/G/H/F/D; 1st 100 Sq Cm or 1% of Body Area Infant/Child
15005 Surg Preparation or Creation of Recipient Site, F/S/E/M/N/E/O/G/H/F/D; Ea Addl 100 Sq Cm or 1% Of Body Area Infant/Child
15271 Skin Subst Graft To Trunk, Arms, Legs, Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area
15272 Skin Subst Graft To Trunk, Arms, Legs, Area Up To 100 Sq Cm; Ea Additional 25 Sq Cm Wound Surface Area, Or Part Thereof
15273 Skin Subst Graft To Trunk, Arms, Legs, Area >/= 100 Sq Cm; 1St 100 Sq Cm Or 1% Of Body Area Of Infants And Children
15274 Skin Subst Graft To Trunk, Arms, Legs, Area >/= 100 Sq Cm; Ea Addl 100 Sq Cm Or Ea Adl 1% Of Body Area Of Inf&Children
15275 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area Up To 100 Sq Cm; 1St 25 Sq Cm Or Less Wound Surface Area
15276 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area Up To 100 Sq Cm; Ea Addl 25 Sq Cm Wound Surface Area, Or Part Thereof
15277 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area >/= 100 Sq Cm; 1St 100 Sq Cm Or 1% Of Body Area Of Infants And Children
15278 Skin Subst Graft To F/S/E/M/N/E/O/G/H/F/D, Area >/= 100 Sq Cm; Ea Addl 100 Sq Cm Or 1% Of Body Area Of Inf And Children
15820 Blepharoplasty Lower Eyelids
15821 Blepharoplasty W Extensive Fat Pads
Prior Authorization List
4
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
15822 Blepharoplasty Upper Eyelid
15823 Rhytidectomy W Excess Skin On Lids
15830 Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy); Abdomen, Infraumbilical Panniculectomy
15832 Exc Excess Skin Subq Tiss Thigh
15833 Exc Excess Skin Leg
15834 Exc Excess Skin Subq Tiss Hip
15835 Exc Excess Skin Buttock
15836 Exc Excess Skin Subq Tiss Arm
15837 Exc Excess Skin Forearm
15838 Exc Excess Skin Subq Tiss Fat Pad
15839 Exc Excess Skin Other Area
15847 Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy), Abdomen
17106 Dest Cut Vasc Proliferative Les to 10 Sq
17107 Dest Cut Vasc Prolif Les 10-50 Sqcm
17108 Dest Cut Vasc Proliferative Les Over 50.
19300 Mastectomy for gynecomastia
19316 Mastopexy
19318 Mammoplasty Reduction
19324 Mammaplasty Augment Wo/Prosthetic Implan
19325 Mammoplasty Augmentation W Implant
19328 Removal of Intact Mammary Implant
19330 Removal Mammary Implant Unilateral
19340 Insert Breast Prosthesis Immediate
19342 Delay Insert Prosthesis Mast/Recons
19350 Reconstruct Nipple/Areolar Unil
19355 Correction Inverted Nipple(S)
19357 Breast Recon W/Tiss Expander Inc Expansi
19361 Breast Recon Latissimus Dorsi Flap W/Wo
19364 Breast Reconstruction W/Free Flap
19366 Reconstruction Breast Other Method
19367 Breast Reconstn W Trans Rectus Abdominis Musc Flap (Tram), SGL Pedicle
19368 Breast Reconstn, Trans Rect Abd Musc Flap (Tram), SGL Ped; Mic Anast
19369 Breast Reconstn W Trans Rectus Abdominis Musc Flap (Tram), DBL Pedicle
19370 Open Periprosthetic Capsulotomy Breast
19371 Capsulectomy Periprosthetic Breast
19380 Revision Reconstructed Breast
19396 Preparation Moulage Breast Implant
20930 Allograft for Spine Surgery; Morselized
20937 Autograft for Spine Surgery; Morselized
20974 Stimulate Bone Electric Noninvasive
20975 Electrical Stim Aid Bone Heal Invasive
Prior Authorization List
5
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)
21070 Coronoidectomy Unilateral
21077 Impression and Custom Preparation; Orbital Prosthesis
21081 Impress/Prep Mandibular Resection
21082 Impress Custom Prep Palatal Augmentation
21083 Impress/Prep Palatal Lift Prosth
21085 Impress/Prep Oral Surgical Splint
21086 Impress Custom Prep Auricular Prosth
21087 Impress/Prep Nasal Prosth
21088 Impress Custom Prep Facial Prosth
21110 Apply Interdental Fixation Other
21121 Genioplasty Sliding Osteotomy Single Pie
21122 Genioplasty Slide Osteotomy 2+
21123 Genioplasty Sliding Augmentation W/Bone
21141 Reconstruction Midface, Single Piece
21142 Reconstruction Midface, Two Pieces
21143 Reconstruction Midface, Three or More Pieces
21145 Recon Midface Lefort I Single Graft
21146 Recon Midface Lefort I 2 Piece W/Bone Gr
21147 Recon Midface Lefort I 3+ Pcs Graft
21150 Recon Midface Lefort II Anterior Intrusi
21151 Recon Midface Lefort II W/Bone Grft
21154 Recon Midface Lefort III Wo/Lefort I
21155 Recon Midface Lefort III W/Lefrt I
21159 Recon Midface Lefort III W/Graft Wo/Lefo
21160 Recon Midface Lefort III W/Grft/L I
21196 Recon Mand Ramus Sag Split W/Rigid Rix
21198 Osteotomy Mandible Segmental
21199 Osteotomy, Mandible, Segmental; with Genioglossus Advancement
21206 Osteotomy Maxilla Segmental
21208 Osteoplasty Facial Bone Augment
21209 Osteoplasty Facial Reduction
21210 Graft Bone Nasal Maxilla Malar Area
21215 Graft Bone Mandible
21230 Grft Rib Cart to Face Chin Nose Ear
21244 Reconstruct Mandible W Bone Plate
21245 Recon Mand Max Subperiosteal Part
21246 Repair Jaw W Subperiost Implnt Tot
21247 Recon Mand Condyle Bone Cart Auto
21248 Recon Mandible Maxilla Endosteal Implant
21249 Repair Jaw W Endosteal Implnt Tot
21256 Recon Orbit W/Osteotomies/Bone Grft
Prior Authorization List
6
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
21260 Periorbital Osteotomy W/Graft Extracrani
21261 Rep Orbit Hypertelorism Combin Appr
21263 Periorbital Osteotomy W/Graft Forehead A
21267 Reposition Orbit Unil Extracranial
21268 Orbit Reposition Unilat W/Graft Intra/Ex
21275 2ndary Revision Orbitocraniofacial Recon
21685 Hyoid Myotomy and Suspension
21740 Recon Rep Pectus Excava/Carinatum
21742 Reconstructive Repair of Pectus Excavatum or Carinatum; Minimally Invasive Approach (Nuss Procedure), Wo Thoracoscopy
21743 Reconstructive Repair of Pectus Excavatum or Carinatum; Minimally Invasive Approach (Nuss Procedure), w Thoracoscopy
22100 Resect Vertebra Part Cervical
22101 Part Resec Vertebral Spinous Process Tho
22102 Resect Vertebra Part Lumbar
22103 Partial Excision of Posterior Vertebral Component for each additional
22110 Exc Vertebra Part Cervical
22112 Exc Vertebra Part Thoracic
22114 Exc Vertebra Part Lumbar
22116 Partial Excision of Vertebral Body for each additional Vertebral Segme
22510 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
22511 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral
22512 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cerv
22513 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb
22514 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb
22515 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 verteb
22532 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy To Prepare Interspace; Thoracic
22533 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy To Prepare Interspace; Lumbar
22534 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy; Thoracic or Lumbar, Each Additional Segment
22548 Arthrodes,Txs/Extraoral,Clivus-C1- 2
22551 Arthrodesis, Anterior Interbody; Cervical Below C2
22552 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each add
Prior Authorization List
7
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
22554 Arthrodesis Ant Interbody-C2 Below
22556 Arthrodesis Ant Interbody- Thoracic
22558 Arthrod,Interbdy Tech;lumbar,Allogf
22590 Arthrodesis Post-Craniocervical
22595 Arthrodesis,Poster.Tech,Atlas- Axis,C1-C2
22600 Fusion Cervical Post < C1
22610 Arthrodesis Post-Thoracic
22612 Arthrodesis,Posterior/Posterolate ral Tec
22614 Arthrodesis, each additional Vertebral Segment
22630 Arthrodesis Post Interbody- Lumbar
22632 Arthrodesis, each additional Interspace
22633 Arthrodesis, Combined Post Or Postlatl Tech W Post Interbdy Tech,Incl Lamectmy &/Discectomy,Sgl Interspace & Segmt; Lumb
22634 Arthrodesis, Combind Post Or Postlatl Tech W Post Interbdy Tech,Incl Lamectmy &/Discectomy,Sgl Interspce & Segmt;Ea Addl
22840 Pos.Instrumnt;e.g. Harringtn Rod
22841 Internal Spinal Fixation by Wiring of Spinous Processes
22842 Instrumentat Post W Segment Wiring
22843 Posterior Segmental Instrumentation, 7 To 12 Vertebral Segments
22844 Posterior Segmental Instrumentation, 13 or More Vertebral Segments
22845 Anterior Instrumentation
22846 Anterior Instrumentation, 4 To 7 Vertebral Segments
22847 Anterior Instrumentation, 8 or More Vertebral Segments
22853 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
22854 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
22856 Total Disc Arthroplasty, Anterior Approach, Including Discectomy with End Plate Preparation, Single Interspace, Cervical
22859 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
22861 Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Cerv
22864 Removal of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Cervical
27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of
27280 Arthrodesis, Sacroiliac Joint
Prior Authorization List
8
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral
27333 Exc Semilunar Cartilage Med + Lat
27412 Autologous Chondrocyte Implantation, Knee
27415 Rep Ligaments Knee+pes Anserin Tran
27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])Advancement Pes Anserinus
27700 Arthroplasty Ankle
27702 Arthroplasty,Ankle; with Implant (Total
27703 Arthroplasty Ankle Second Reconstr
27704 Removal of Ankle Implant
28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant
29861 Arthroscopy, Hip, Surgical; With Removal Of Loose Body Or Foreign Body
29862 Arthroscopy, Hip, Surg; W Chondroplsty, Arthroplsty, &/ Labrum Resectn
29863 Arthroscopy, Hip, Surgical; With Synovectomy
29866 Arthroscopy, Knee, Surgical; Osteochondral Autograft(S) (Eg, Mosaicplasty) (Includes Harvesting Of The Autograft)
29867 Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty)
29868 Arthroscopy, Knee, Surgical; Meniscal Transplantation (Includes Arthrotomy For Meniscal Insertion), Medial Or Lateral
29879 Arthroscopy Knee
29886 Arthrosc,Knee,Surg;drill-Intact Ost.Diss
30400 Rhinoplasty Primary Partial
30410 Rhinoplas,Prim;complet,Extern.P arts
30420 Rhinoplasty Primary Maj Septal Rep
30430 Rhinoplasty,2ndary;minor Revision
30435 Rhinoplasty,Intermed Revis-Bony Work W O
30450 Rhinoplasty,2ndary;major Revision
30460 Rhinoplsty For Deform Tip Only
30462 Rhinoplsty For Deform Tip/Sept/Oste
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g. balloon dilation), transnasal or via canine fossa
31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g. balloon dilation)
31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g. Balloon dilation)
32664 Thoracoscopy, Surgical; with Thoracic Sympathectomy
32850 Donor Pneumonectomy(ies) W Prep and Maintenance of Allograft (Cadaver)
32851 Lung Transplant, Single; Without Cardiopulmonary Bypass
32852 Lung Transplant, Single, with Cardiopulmonary Bypass
32853 Lung Transplant, Double (Sequential or En Bloc); Without Cardpulm Bypa
32854 Lung Transplant, Double (Sequential or En Bloc); with CardPulm Bypass
32855 Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Unilateral
32856 Backbench Standard Preparation Of Cadaver Donor Lung Allograft; Bilateral
Prior Authorization List
9
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
33282 Implantation of patient-activated cardiac event recorder
33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
33930 Donr Cardiectmy- Pneum,Prep/Main.Hom
33933 Backbench Standard Preparation Of Cadaver Donor Heart/Lung Allograft
33935 Heart-Lung Transplant W Recipient Cardi/
33940 Donor Cardiectomy,Prep/Mainten.Hom o
33944 Backbench Standard Preparation Of Cadaver Donor Heart Allograft
33945 Heart Transplant, W/Wo Recipient Cardiec
33975 Implantation of Ventricular Assist Device; Single Ventricle Support
33976 Implantation of Ventricular Assist Device; Biventricular Support
33979 Insertion Of Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle
33990 Insertion Of Ventricular Assist Device, Percutaneous; Arterial Access Only
33991 Insertion Of Ventricular Assist Device, Percutaneous; Both Arterial And Venous Access, With Transseptal Puncture
34841 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrate
34842 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrate
34843 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrate
34844 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrate
34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption
34846 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption
34847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption
34848 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption
36215 Intro Cath Head/Neck Artery
36216 Select Cath Plcmt Art; 2nd Order Thoraci
36217 Select Cath Plcmt Art;3rd Ord Thrc
36218 Select Cath Plcmt Art; Add 2nd/3rd Order
36468 1+ Injec-Scler.Solutions,Spider Vein; Li
36470 Injection Sclerosing Solution Single Vei
36471 Inject Sclerosing Agent Mult Veins
36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
Prior Authorization List
10
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
36474 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36475 Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Radiofrequency; First Vein Treated
36476 Endovenous Ablation Therapy Incompetent Vein, Extremity, Percut, Radiofreq; 2nd & Subsequent Veins,Same Extrem,Sep Sites
36478 Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Laser; First Vein Treated
36479 Endovenous Ablation Therapy Incompetent Vein, Extremity, Percutaneous, Laser; 2nd & Subseq Veins, Same Extrem, Sep Sites
36516 Therapeutic Apheresis; with Extracorporeal Selective Adsorption or Selective Filtration and Plasma Reinfusion
37188 Percutaneous transluminal mechanical thrombectomy, vein(s), repeat treatment on subsequent day of thrombolytic therapy
37700 Lig/Div.Saph.Vein at Junc/Interrupt
37718 Ligation, division, and stripping, short saphenous vein
37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below
37735 Ligation & Strip Saphen+ulcer Unil
37760 Ligation Perforators Rad (Linton)
37761 Ligation of Perforator Vein(s), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg
37765 Stab Phlebectomy of Varicose Veins, One Extremity; 10-20 Stab Incisions
37766 Stab Phlebectomy of Varicose Veins, One Extremity; More Than 20 Incisions
37780 Ligation/Divis-Short Saph.Vein @ Sapheno
37785 Ligation 2ndary Varicose Vein Unil
38204 Management of Recipient Hematopoietic Progenitor Cell Donor Search and Cell Acquisition
38205 Blood-Derived Hematopoietic Progenitor Cell Harvesting for Transplantation, Per Collection; Allogenic
38206 Blood-Derived Hematopoietic Progenitor Cell Harvesting for Transplantation, Per Collection; Autologous
38207 Transplant Preparation of Hematopoietic Progenitor Cells; Cryopreservation and Storage
38208 Transplant Preparation of Hematopoietic Progenitor Cells; Thawing of Previously Frozen Harvest
38209 Transplant Preparation of Hematopoietic Progenitor Cells; Washing of Harvest
38210 Transplant Preparation of Hematopoietic Progenitor Cells; Specific Cell Depletion Within Harvest, T-Cell Depletion
38211 Transplant Preparation of Hematopoietic Progenitor Cells; Tumor Cell Depletion
38212 Transplant Preparation of Hematopoietic Progenitor Cells; Red Blood Cell Removal
38213 Transplant Preparation of Hematopoietic Progenitor Cells; Platelet Depletion
38214 Transplant Preparation of Hematopoietic Progenitor Cells; Plasma (Volume) Depletion
38215 Transplant Preparation of Hematopoietic Progenitor Cells; Cell Concentration in Plasma,
Prior Authorization List
11
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
Mononuclear, or Buffy Coat Layer
38230 Harvest Bone Marrow For Transplant
38232 Bone Marrow Harvesting For Transplantation; Autologous
38240 Bone Marrow Transplantation; Allogenic
38241 Bone Marrow Transplant; Autologous
38242 Bone Marrow or Blood-Derived Peripheral Stem Cell Transplantation; Allogeneic Donor Lymphocyte Infusions
41120 Glossectomy; less than one-half tongue
41500 Fixation of tongue, mechanical, other than suture (eg, K-wire)
42120 Resect Palateor Extensive Lesion
42140 Uvulectomy
42145 Uvuloplatopharyngoplasty
42160 Destruct Lesion Palate/Uvula
42226 Lengthening of Palate, and Pharyngeal Fl
42227 Lengthen Palate W Island Flap
42235 Repair Anterior Palate Including Vomer F
42950 Pharyngoplasty
42953 Repair Pharyngoesophageal
43327 Esophagogastric Fundoplasty Partial Or Complete; Laparotomy
43644 Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux-En-Y Gastroenterostomy (Roux Limb <= 150 Cm)
43645 Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass And Small Intestine Reconstruction
43647 Laparoscopy, Surgical; Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum
43648 Laparoscopy, Surgical; Revision or Removal of Gastric Neurostimulator Electrodes, Antrum
43659 Unlisted laparoscopy procedure, stomach
43770 Laparoscopy, surg, gastric restrictive procedure; placement of adjustable gastric band
43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only
43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only
43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only
43774 Laparoscopy, surg, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components
43775 Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy (ie, Sleeve Gastrectomy)
43843 Gastroplsty Non Vert-Banded Obesity
43845 Gastric Stapling Morbid Obesity
43846 Gastric Bypass W/Roux-En-Y- Mor.Obes
43847 Gstrc Restricve Prcd w Gstrc Byps F Morbid Obesty; w/Sml Bowel Rcnstn
Prior Authorization List
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On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
43848 Revision of Gastrc Restrictive Prcd For Morbid Obesity (Separate Prcd)
43850 Rev Gastroduodenostomy Wo Vagotomy
43855 Revis.Gastroduo.Anast,Recons;w /Vag
43860 Rev Gastrojejunostomy Wo Vagotomy
43865 Gastrojejunostomy;with Vagotomy
43881 Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum, Open
43882 Revision or Removal of Gastric Neurostimulator Electrodes, Antrum, Open
44133 Donor Enterectomy, Open, w Allograft Prep & Maintenance; Living Donor
44136 Intestinal Allotransplantation; From Living Donor
47133 Donor Hepatectomy,W Prep & Maintenance-H
47135 Transplant Liver (Recipient)
47140 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Left Lateral Segment Only
47141 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Left Lobectomy
47142 Donor Hepatectomy, with Preparation and Maintenance of Allograft, Living Donor; Total Right Lobectomy
47143 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; Without Trisegment Or Lobe Split
47144 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; W Trisegment Split Of Graft Into Two Partial Grafts
47145 Backbench Standard Preparation Of Cadaver Donor Whole Liver Graft; With Lobe Split Of Graft Into Two Partial Grafts
47146 Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Venous Anastomosis, Each
47147 Backbench Reconstruction Of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Arterial Anastomosis, Each
47370 Laparoscopy, Surgical, Ablation Of One Or More Liver Tumor(S); Radiofrequency
47371 Laparoscopy, Surgical, Ablation Of One Or More Liver Tumor(S); Cryosurgical
47379 Unlisted Laparoscopic Procedure, Liver
47380 Ablation, Open, Of One Or More Liver Tumor(S); Radiofrequency
47381 Ablation, Open, Of One Or More Liver Tumor(S); Cryosurgical
47382 Ablation, One Or More Liver Tumor(S), Percutaneous, Radiofrequency
47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation
48550 Donor Pancreatectomy For Transplantation
48551 Backbench Standard Preparation Of Cadaver Donor Pancreas Allograft
48552 Backbench Reconstruction Of Cadaver Donor Pancreas Allograft Prior To Transplantation, Venous Anastomosis, Each
48554 Transplantation of Pancreatic Allograft
48556 Removal of Transplanted Pancreatic Allograft
50300 Nephrectomy Cadaver Donor
Prior Authorization List
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On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
50320 Donor Nephrectomy;from Living Donor,Unil
50323 Backbench Standard Preparation Of Cadaver Donor Renal Allograft
50325 Backbench Standard Preparation Of Living Donor Renal Allograft (Open Or Laparoscopic)
50327 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Venous Anastomosis, Each
50328 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Arterial Anastomosis, Each
50329 Backbench Reconstruction Of Cadaver Or Living Donor Renal Allograft Prior To Transplantation; Ureteral Anastomosis, Each
50340 Nephrectomy Recipient Unilateral
50360 Transplant Renal Homograft
50365 Renal Homotxplnt,Implnt Gft;w/Recipnt Ne
50370 Removal of Transplanted Homograft
50380 Transplant Renal Autograft
50547 Laparoscopy, surgical; donor nephrectomy from living donor
52287 Cystourethroscopy, With Injection(s) For Chemodenervation Of The Bladder
53860 Transurethral Radiofrequency Micro-Remodeling Of The Female Bladder Neck And Proximal Urethra
55873 Cryosurgical Ablation of the Prostate (Incl Ultrasonic Probe Placemnt)
61517 Implantation of Brain Intracavitary ChemoTherapy Agent
61650 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory
61651 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition to code for primary procedure)
61850 Twst Drl/Brr Hole-Impl Elec;corticl
61860 Craniec/Otmy Impln- Elec,Cerebr;cort
61863 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First Array
61864 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; ea addl Array
61867 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First Array
61868 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; ea addl Array
61880 Revis/Remv Intracr.Neurost.Electrod
62287 Asp Percutaneous Diskectomy One/Mult Lev
62290 Inj Proc Diskography Ea Level; Lumb
62291 Inject For Diskography Cervical
63001 Laminec-Expl/Decomp,1,2 Segm;cerv.
63003 Decompress Spine <2 Seg Thoracic
63005 Laminec=expl/Decomp,1,2 Segm;lumb
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
63011 Laminec-Expl/Decomp,1,2 Segm;sacr
63012 Laminectomy/Rem Facets,Lumbar (Gill Type
63015 Laminec-Expl/Dec,3+seg;cerv
63016 Decompress Spine >2 Seg Thoracic
63017 Laminec-Expl/Dec,3+seg;lumb
63020 Exc Iv Disk Cervical Unilat
63030 Exc Iv Disk Lumbar Unilat
63035 Exc Iv Disk Cervical/Lumb >1 Space
63040 Laminotomy W Dec Nrv Rts;reex;cerv
63042 Laminotomy W Dec Nrv Rts;reex;lumb
63043 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Cerv Interspace
63044 Laminotomy w Decompressn Nerve Root, Reexplor; Ea Addl Lumb Interspace
63045 Laminectomy W Facetectomy- Cervical
63046 Laminect, 1 Segm;thoracic
63047 Laminectomy W Facetectomy- Lumbar
63048 Lam.,Facetect,Foraminot;ea Adtl.Seg
63050 Laminoplasty, Cervical, With Decompression Of The Spinal Cord, Two Or More Vertebral Segments;
63051 Laminoplasty, Cerv, W Decompression Of Spinal Cord, 2 Or > Verteb Segments; W Reconstruction Of Posterior Bony Elements
63055 Decompress Spine Transpedic- Thorac
63056 Transped App/Decomp;sgle;lumb
63057 Decomp Spine Transpedic-Ea Add Seg
63064 Decompress Spine Costoverteb 1 Seg
63066 Decomp Spine Costoverteb-Ea Add Seg
63075 Diskectomy,Ante.W/Decomp Cord/Root;cerv;
63076 Exc Iv Disk Ant Cervical >1 Seg
63077 Diskectomy,Ante.W/Decomp Cord/Root;thor;
63078 Exc Iv Disk Ant Thoracic-Ea Add Seg
63081 Vert Corpectomy,Part/Comp.;anter.A pp;cer
63082 Corpecto Verteb Ant Cerv Ea Add Seg
63085 Vert Corpect.,Part/Comp,Transthoraci c;th
63086 Corpecto Verteb Thoracic Ea Add Seg
63087 Vert.Corpect;thoracolumbar/Tho r/Lumbar;s
63090 Vert.Corpec;peritoneal Appr.;single
63101 Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression of Spinal Cord/Nerve Roots; Thoracic, Sgl Segment
63103 Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression Spinal Cord/Nerve Rts; Thoracic/Lumbar, ea addl Seg
63170 Laminectomy W Myelotomy;cerv,Thoracic,Th
63180 Section Dentate Lig Cervical <2 Seg
63182 Laminec/Section Ligaments W/Wo Grft,Cerv
63185 Rhizotomy <2 Segments
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On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
63190 Rhizotomy >2 Segments
63191 Section Spinal Accessory Nerve Unil
63194 Cordotomy Unilat 1 Stage Cervical
63195 Cordotomy Unilat 1 Stage Thoracic
63196 Cordotomy Bilat 1 Stage Cervical
63197 Laminect W Cordotomy;both Tracts;1 Stg;t
63198 Cordotomy Bilat 2 Stage Cervical
63199 Laminect.W Cordotmy;both Tracts;2 Stg;th
63200 Relase Tethered Spinal Cord
63265 Laminect;intraspinal Lesion;cerv.
63266 Exc Les Intraspin Extradur- Thoracic
63267 Laminect;intraspinal Lesion;lumb
63270 Lamin-Exc Intrasp.Les,Intradur;cerv
63271 Exc Les Intraspin Intradur- Thoracic
63272 Lamin-Exc Intrasp.Les,Intradur;lumb
63275 Lam,Bx/Exc Intrasp.Neo;extradur,Cer
63276 Exc Intraspin Neopl Extradur- Thorac
63280 Lam,Bx/Exc Int.Neo;intra,Extra,Cerv
63281 Exc Intraspin Neopl Extramed- Thorac
63285 Lam,Bx/Exc In.Neo;intradur,Im,Cerv
63286 Exc Intraspin Neopl Intramed- Thorac
63287 Lam,Bx/Exc Neo;intradur,Im,Thoracol
63295 Osteoplastic Reconstruction Of Dorsal Spinal Elements, Following Primary Intraspinal Procedure (List Sep)
63300 Vert.Corpectmy,1 Seg;extradurl,Cerv
63301 Corpectomy Verteb-Thorac Transthor
63302 Vert.Corpectm,1;extra,Thor- Thoracol
63304 Vert.Corpectmy,1 Seg;intradurl,Cerv
63305 Corpectomy Verteb-Thorac Transthor
63306 Vert.Corp,1;intradur,Thor- Thoracol
63307 Vert.Corpec,Exc Les,1;intradur,Lumb/Sac-
63308 Vertebral Corpectomy;ea.Add.Segment
63650 Percut.Impl- Neurostm.Electrod;epidu
63655 Lam-Impl- Neurostim.Electrod;epidurl
63661 Removal of Spinal Neurostimulator Electrode Percutaneous Array(s), Including Fluoroscopy, When Performed
63662 Removal of Spinal Neurostimulator Electrode Plate/Paddle(s) Placed Via Laminotomy or Laminectomy, inc Fluoro
63663 Revision including Replacement, When Performed, of Spinal Neurostimulator Electrode Percutaneous Array(s), inc Fluoro
63664 Revision inc Replacement, If Performed, of Spinal Neurostimr Electrode Plate/Paddles Placed Via Laminotomy/Ectomy
Prior Authorization List
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
63685 Placement Subcut Neurostim Receiver
63688 Rev/Rem. Implted. Generator/Rec.
64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
64553 Percutaneous implantation of neurostimulator electrode array; cranial nerve
64561 Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, if performed
64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)
64590 I & Plcmt. Peripheral Generator/Rec
64595 Rev Peripheral Neurostim Receiver
64612 Dest Neurolytic Agent; Muscle Enervated
64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
64617 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed
64633 Destruction By Neurolytic Agt, Paraverteb Facet Jt Nrvs, W Imaging Guidance; Cervical Or Thoracic, Single Facet Joint
64634 Destruction By Neurolytic Agt, Paraverteb Facet Joint Nrvs, W Imaging Guidance; Cervical Or Thoracic, Ea Addl Facet Jt
64635 Destruction By Neurolytic Agt, Paraverteb Facet Jt Nrvs, W Imaging Guidance; Lumbar Or Sacral, Single Facet Joint
64636 Destruction By Neurolytic Agt, Paraverteb Facet Joint Nrvs, W Imaging Guidance; Lumbar Or Sacral, Ea Addl Facet Jt
64642 Chemodenervation of one extremity; 1-4 muscle(s)
64643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)
64644 Chemodenervation of one extremity; 5 or more muscle(s)
64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary procedure)
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)
64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s)
64650 Chemodenervation of eccrine glands; both axillae
64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day
67900 Repair Brow Ptosis (Supraciliary/Mid/Cor
Prior Authorization List
17
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
67901 Repair Blepharoptosis; Frontalis
67902 Rep Blepharoptosis Frontalis+sling
67903 Rep. Bleph;adv.;internal Appr.
67904 Rep Blepharoptosis Levator External
67906 Rep.Bleph;sup.Rectus Tech,Fasc.Slng
67908 Rep.Bleph;conjunct-Tarso- Lev.Resec
69714 Implantation, osseointetrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
69930 Cochlear Device Implantation, W/Wo Masto
70336 Magnetic Resonance (Eg, Proton) Imaging,
70450 Ct,Head/Brain;w/O Contrast Material
70460 C A T Heador Brain; with Contrast Mater
70470 Ct,Head/Brain;w/O,W Contrst Mater'L
70480 C A T Orbit,Sella/Post Fossa,Ear;w/O Con
70481 Ct,Orbit,Sella,Fossa,Ear;w/Contra st
70482 C A T Orbit,Sella/P.Fossa,Ear;wo/W Contr
70486 Ct,Maxillofac.Area;w/O Cntrst Mat'L
70487 C A T Maxillofacial Area; W/Contrast Mat
70488 Ct,Max-Facial Area;w/O,W Cntrst Mat
70490 C A T Soft Tissue Neck; W/O Contrast Mat
70491 Ct,Soft Tissue Neck;w/Contrast Mat.
70492 C A T Soft Tissue Neck;w/O Then W/Contr.
70496 Ct Angiography, Head, w/o Contrast then w Contrast & Further Sections
70498 Ct Angiography, Neck, w/o Contrast then w Contrast & Further Sections
70540 Mri; Orbit, Face, & Neck
70542 MRI, Orbit, Face, And Neck; with Contrast Material(S)
70543 MRI, Orbit, Face, Neck; wo Contrast then w Contrast, Further Sequences
70544 Magnetic Resonance Angiography, Head; without Contrast Material(s)
70545 Magnetic Resonance Angiography, Head; with Contrast Material(s)
70546 Mr Angiography, Head; w/o Contrast then w Contrast & Further Sequences
70547 Magnetic Resonance Angiography, Neck; without Contrast Material(s)
70548 Magnetic Resonance Angiography, Neck; with Contrast Material(s)
70549 Mr Angiography, Neck; w/o Contrast then w Contrast & Further Sequences
70551 Magnetic Resonance Imag,Brain;w/O Contra
70552 Mri, Brain; W/Contrast Material(S)
70553 Mri Brain; W/O Contrast & W/Contrast & A
70554 MRI, Brain, Functional; inc Test Selection and Admin of Repetitive Body Part Movement & Visual Stim, wo Phys/Psycholgst
70555 MRI, Brain, Functional; Requiring Physician or Psychologist Administration of Entire Neurofunctional Testing
71250 Ct, Thorax; W/O Contrast Material
Prior Authorization List
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On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
71260 C A T Thorax; W/Contrast Material
71270 Ct, Thorax; W/O Then W/Contrast
71275 Ct Angiography, Chest, w/o Contrast then w Contrast & Further Sections
71550 Magnetic Resonance Imaging,Chest-Eval.Ly
71551 MRI, Chest (Eg, For Lymphadenopathy Eval); with Contrast Material(s)
71552 MRI, Chest; w/o Contrast then with Contrast And Further Sequences
71555 Magnetic Resonance Angiography, Chest (exclusing myocardium) W or Wo Contrast Materials
72125 Cat Cerv.Spine;w/O Contrst Material,18-2
72126 Ct Cervical Spine;w/Contrast Mater.
72127 Cat,Cerv.Spine;w/O,With Contrast Materia
72128 Ct Thoracic Spine;w/0 Contrast Mat.
72129 Cat,Thoracic Spine;w/Contrst Materl,18-2
72130 Ct Thorac.Spine;w/O,Then W/Contrast
72131 Cat Lumbar Spine;w/O Contrst Materl,18-2
72132 Ct Lumbar Spine;w/Contrast Material
72133 Cat,Lumbar Spine;w/O,With Contrast Mater
72141 Mri,Spin.Canal,Cerv;w/O Contrst Mat
72142 Mri,Spinal Canal/Contents,Cerv;w/Contrst
72146 Mri,Spin.Canal,Thor;w/O Cntrst Matl
72147 Mri,Spinal Canal/Contents,Thorac;w/Cntrs
72148 Mri,Spin.Canal,Lumb;w/O Cntrst Matl
72149 Mri,Spinal Canal/Contents,Lumbar;w/Cntrs
72156 Mri Spinal Wo & W Contrast: Cerv
72157 Mri Spinal Canal Wo & W Contrast; Thorac
72158 Mri Spinal Wo & W Contrast: Lumbar
72159 Magnetic Resonance Angiography Spine and Contents W/WO Contrast
72191 Ct Angiography, Pelvis, w/o Contrast then w Contrast, Further Sections
72192 Ct Pelvis; W/O Contrast Material
72193 C A T Pelvis; with Contrast Material(S)
72194 Ct Pelvis;w/O,Then W/Contrast Mater
72195 MRI, Pelvis; without Contrast Material(s)
72196 Magnetic Resonance (Eg, Proton) Imaging,
72197 MRI, Pelvis; w/o Contrast then with Contrast And Further Sequences
72198 Magnetic Resonance Angiography Pelvis W/WO Contrast
72285 Diskography Cervical Rad S&I
72295 Diskography Lumbar Rad S&I
73200 C A T Upper Extremity; W/O Contrast Mate
73201 Ct Upper Extremity;w/Contrast Mater
73202 C A T Upper Extremity;w/O Then W/Contr.M
73206 Ct Angiography, Upper Extremity, w/o then w Contrast, Further Sections
73218 MRI, Upper Extremity, Other Than Joint; without Contrast Material(s)
73219 MRI, Upper Extremity, Other Than Joint; with Contrast Material(s)
Prior Authorization List
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On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
73220 Magnetic Resonance Imag, Upper Extrem, N
73221 Mri, Any Joint of Upper Extremity
73222 MRI, Any Joint of Upper Extremity; with Contrast Material(s)
73223 MRI, Any Joint, Upper Extremity; w/o then w Contrast&Further Sequences
73225 Magnetic Resonance Angiography Upper Extremity W/WO Contrast
73700 C A T Lower Extremity; W/O Contrast Mate
73701 Ct,Lower Extremity;w/Contrast Mater
73702 C A T Lower Extremity;w/O Then W/Contr.M
73706 Ct Angiography, Lower Extremity, w/o then w Contrast&Further Sections
73718 MRI, Lower Extremity Other Than Joint; without Contrast Material(s)
73719 MRI, Lower Extremity Other Than Joint; with Contrast Material(s)
73720 Mri Lower Extremity,Other Than Jnt
73721 Magnetic Resonance Imaging, Any Jnt-Lowe
73722 MRI, Any Joint of Lower Extremity; with Contrast Material(s)
73723 MRI, Any Joint of Lower Extremity; w/o then w Contrast, More Sequences
73725 Magnetic Resonance Angiography LowerExtremity W/WO Contrast
74150 Ct Abdomen; W/O Contrast Material
74160 C A T Abdomen; with Contrast Material(S)
74170 Ct Abdomen;w/O,Then W/Contrast Mat
74174 Computed Tomographic Angiography, Abdomen And Pelvis, With Contrast Material(s), Including Noncontrast Images
74175 Ct Angiography, Abdomen, wo Contrast then w Contrast, Further Sections
74176 Computed Tomography, Abdomen And Pelvis; Without Contrast Material
74177 Computed Tomography, Abdomen And Pelvis; With Contrast Material(S)
74178 Ct, Abdomen And Pelvis; W/O Contrast Material In One Or Both Body Regions, Followed By Contrst Mats And Further Sections
74181 Magnetic Resonance Imaging,Abdomen
74182 MRI, Abdomen; with Contrast Material(s)
74183 MRI, Abdomen; w/o Contrast then with Contrast And Further Sequences
74185 Magnetic Resonance Angiography Abdomen W/WO Contrast
74261 Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; without Contrast Material
74262 CT Colonography, Diagnostic, including Image Postprocessing; W Contrast Materials inc Non- Contrast Images, If Performed
74263 Computed Tomographic (CT) Colonography, Screening, Including Image Postprocessing
74712 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; single or first gestation
74713 Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging when performed; each additional gestation (List separately in addition to code for primary procedure)
75557 Cardiac Magnetic Resonance Imaging for Morphology and Function without Contrast Material;
75559 Cardiac Magnetic Resonance Imaging for Morphology and Function without Contrast Material; with Stress Imaging
Prior Authorization List
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
75561 Cardiac MRI wo Contrast Followed by Contrast and Further Sequences;
75563 Cardiac MRI wo Contrast Followed by Contrast and Further Sequences; with Stress Imaging
75565 Cardiac MRI for velocity flow mapping
75571 CT Heart w/o Contrast; quantitative eval of coronary calcium
75572 CT Heart w/ Contrast; eval of cardiac structure and morphology
75573 CT Heart w/ Contrast; eval of cardiac structure and morphology in setting of congenital heart disease
75574 CT angiography, heart, coronary arteries, and bypass grafts
75635 Ct Angio, Aorta&Iliofemoral, Rad Sup&Int, wo, w Contrast, Addl Sectns
75665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation
75685 Angiography Vertebral Cervical Intracran
76376 3D rendering w/ interpretationand reporting of CT MRI, US or other Tomographyic modality with image postprocessing under concurrent supervision
76380 CT, limited or localized follow-up study
76390 Magnetic Resonance Spectroscopy
77058 Magnetic Resonance Imaging, Breast, without and/or with Contrast Material(s); Unilateral
77059 Magnetic Resonance Imaging, Breast, without and/or with Contrast Material(s); Bilateral
77078 Computed Tomography, Bone Mineral Density Study, 1 or More Sites; Axial Skeleton (Eg, Hips, Pelvis, Spine)
77084 Magnetic Resonance (Eg, Proton) Imaging, Bone Marrow Blood Supply
77520 Proton beam delivery to a sgl treatment area, sgl port, custom block
77522 Proton Treatment Delivery; Simple, with Compensation
77523 Proton beam delivery to one or two treatment areas, two or more ports, two or more custom blocks
77525 Proton Treatment Delivery; Complex
77767 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel
77768 Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions
77770 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel
77771 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels
77772 Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels
78459 Myocardial Imaging
78466 Myocardial Imge Infarct;
78468 Myocardial Img Infarct; Eject 1pass
78469 Myocardial Image Infarct; Spect
78472 Card Bld Pool Image; 1 Rest W/Motn
78473 Cardiac Blood Pool; Mult Study Rest & St
78481 Cardiac Blood Pool 1st Pass; Single at R
78483 Cardiac Blood Pool 1st Pass; Mult
78491 Myocardial Imaging, Pet, Perfusion; Single Study Rest/Stress
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
78492 Myocardial Imaging, Pet, Perfusion;Multiple Studies Rest And/Or Stress
78494 Cardiac blood pool imaging gated equilib SPECT at rest wall motion study + eject fract w/wo quant process
78496 cardiac Blood Pool Imaging, single study
78608 Brain Imaging Positron Emission Tomography
78609 Brain Imaging Positron Emission Tomography Perfusion Evaluation
78811 Tumor Imaging, Positron Emission Tomography (Pet); Limited Area (Eg, Chest, Head/Neck)
78812 Tumor Imaging, Positron Emission Tomography (Pet); Skull Base To Mid-Thigh
78813 Tumor Imaging, Positron Emission Tomography (Pet); Whole Body
78814 Tumor Imaging, Positron Emission Tomography (Pet) W Concurrently Acquired Ct; Limited Area (Eg, Chest, Head/Neck)
78815 Tumor Imaging, Positron Emission Tomography (Pet) W Concurrently Acquired Ct; Skull Base To Mid-Thigh
78816 Tumor Imaging, Positron Emission Tomography (Pet) W Concurrently Acquired Ct; Whole Body
81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis
81200 Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis, Common Variants (Eg, E285A, Y231X)
81201 APC (Adenomatous Polyposis Coli) Gene Analysis; Full Gene Sequence
81202 APC (Adenomatous Polyposis Coli) Gene Analysis; Known Familial Variants
81203 APC (Adenomatous Polyposis Coli) Gene Analysis; Duplication/Deletion Variants
81205 Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1, Beta Polypeptide) Gene Analysis, Common Variants
81210 Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg, Colon Cancer), Gene Analysis, V600E Variant
81211 Brca1, Brca2 Gene Analysis; Full Sequence Analysis And Common Duplication/Deletion Variants In Brca1
81212 Brca1, Brca2 Gene Analysis; 185Delag, 5385Insc, 6174Delt Variants
81214 Brca1 Gene Analysis; Full Sequence Analysis And Common Duplication/Deletion Variants
81215 Brca1 (Breast Cancer 1) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant
81216 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis
81217 Brca2 (Breast Cancer 2) (Eg, Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant
81225 Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 19), Gene Analysis, Common Variants
81226 Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide 6), Gene Analysis, Common Variants
81227 Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9), Gene Analysis, Common Variants (Eg, *2, *3, *5, *6)
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contract terms.
81228 Cytogenomic Constitutional (Genome-Wide) Microarray Analysis; Interrogation Of Genomic Regions For Copy Number Variants
81229 Cytogenomic Constitutional Microarray Analysis;Interrog Genomic Regns For Copy Numbr & Sgl Nuctide Polymorphism Variants
81235 EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q)
81240 F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene Analysis, 20210G>A Variant
81241 F5 (Coagulation Factor V) (Eg, Hereditary Hypercoagulability) Gene Analysis, Leiden Variant
81243 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis; Evaluation To Detect Abnormal (Eg, Expanded) Alleles
81244 Fmr1 (Fragile X Mental Retardation 1) Gene Analysis; Characterization Of Alleles
81250 G6Pc (Glucose-6-Phosphatase, Catalytic Subunit) Gene Analysis, Common Variants (Eg, R83C, Q347X)
81255 Hexa (Hexosaminidase A [Alpha Polypeptide]) Gene Analysis, Common Variants (Eg, 1278Instatc, 1421+1G>C, G269S)
81256 Hfe (Hemochromatosis) (Eg, Hereditary Hemochromatosis) Gene Analysis, Common Variants (Eg, C282Y, H63D)
81260 Inhibtr Of Kappa Light Plypeptide Gene Enhancr In B-Cells, Kinase Complex-Assoc Protein Gene Analysis, Common Variants
81275 Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In Codons 12 And 13
81276 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146)
81280 Long Qt Syndrome Gene Analyses; Full Sequence Analysis
81281 Long Qt Syndrome Gene Analyses; Known Familial Sequence Variant
81282 Long Qt Syndrome Gene Analyses; Duplication/Deletion Variants
81287 MGMT, methylation analysis
81288 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis
81290 Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene Analysis, Common Variants (Eg, Ivs3-2A>G, Del6.4Kb)
81291 Mthfr (5,10- Methylenetetrahydrofolate Reductase) (Eg, Hereditary Hypercoagulability) Gene Analysis, Common Variants
81292 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Full Sequence Analysis
81293 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Known Familial Variants
81294 Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) Gene Analysis; Duplication/Deletion Variants
81295 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Full Sequence Analysis
81296 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Known Familial Variants
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
81297 Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) Gene Analysis; Duplication/Deletion Variants
81298 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Full Sequence Analysis
81299 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Known Familial Variants
81300 Msh6 (Muts Homolog 6 [E. Coli]) Gene Analysis; Duplication/Deletion Variants
81302 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Full Sequence Analysis
81303 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Known Familial Variant
81304 Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Duplication/Deletion Variants
81311 NRAS (neuroblastoma RAS viral [v ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61)
81313 PCA3/KLK3 (prostate cancer antigen 3 {non-protein coding}/ kallikrein-related peptidase 3 {prostate specific antigen} ratio (eg prostate cancer)
81315 Promyelocytic Leukemia/Retinoic Acid Receptor Alpha, (T(15;17)), Translocation Analysis; Common Breakpoints, Qual/Quant
81316 Promyelocytic Leukemia/Retinoic Acid Receptor Alpha, (T(15;17)), Translocation Analysis; Single Breakpoint, Qual/Quant
81317 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Full Sequence Analysis
81318 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Known Familial Variants
81319 Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) Gene Analysis; Duplication/Deletion Variants
81321 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Full Sequence Analysis
81322 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Known Familial Variant
81323 PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Duplication/Deletion Variant
81324 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Duplication/Deletion Analysis
81325 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Full Sequence Analysis
81326 PMP22 (Peripheral Myelin Protein 22) Gene Analysis; Known Familial Variant
81327 SEPT9 (Septin9) (eg, colorectal cancer) methylation analysis
81330 Smpd1(Sphingomyelin Phosphodiesterase 1, Acid Lysosomal) (Eg, Niemann-Pick Disease, Type A) Gene Analysis, Common Vars
81331 Snrpn/Ube3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase E3A), Methylation Analysis
81332 Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha-1 Antiproteinase, Antitrypsin, Member 1), Gene Analysis,Common Vars
81350 Ugt1A1 (Udp Glucuronosyltransferase 1 Family, Polypeptide A1) (Eg, Irinotecan Metabolism), Gene Analysis,Common Variants
81355 Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (Eg, Warfarin Metabolism), Gene Analysis, Common Variants
81382 HLA class II typing, high resolutionn (ie, alleles or allele groups); one locus (eg, HLA- DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each
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81400 Molecular Pathology Procedure Level 1
81401 Molecular Pathology Procedure Level 2
81402 Molecular Pathology Procedure Level 3
81403 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons
81404 Molecular Pathology Procedure Level 5
81405 Molecular Pathology Procedure Level 6
81406 Molecular Pathology Procedure Level 7
81407 Molecular Pathology Procedure Level 8
81408 Molecular Pathology Procedure Level 9
81412 Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1
81413 Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A
81414 Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1
81415 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis
81416 Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code
81417 Exome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syn
81420 Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromoso
81422 Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood
81432 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 14 genes, including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53
81433 Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11
81435 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including
81436 Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, i
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
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81437 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL
81438 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL
81439 Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN
81442 Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio- cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1
81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score
81507 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy
81508 Fetal congenital abnormalities, biochemical assays of 2 proteins
81509 Fetal congenital abnormalities, biochemical assays of 3 proteins
81510 Fetal congenital abnormalities, biochemical assays of three analytes
81511 Fetal congenital abnormalities, biochemical assays of 4 analytes
81512 Fetal congenital abnormalities, biochemical assays of 4 analytes
81525 Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a recurrence score
81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival
81540 Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype
81545 Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious)
81595 Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score
82106 Alpha-fetoprotein; amniotic fluid
83020 Hemoglobulin frantionation and quantitation, electrophoresis
83021 Hemoglobin fractionation and quantitation, chromatography
86001 Allergen Specific Igg Quantitative or Semiquantitative, Each Allergen
86003 Allergen Specific IGE each Panel
86005 Allergen Specific IGE Multiallergen Screen
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86813 Tissue Typing,Hla Typing, A,B,&/Or C,Mul
86816 Hla Typing Dr/Dq Single Antigen
86817 Hla Typing Dr/Dq Multiple Antigens
86821 Hla Typing Lymphocyte Culture Mixed
86822 Hla Typing Lymphocyte Culture Prime
88235 tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells
88240 cryopreservation, freezing and storage of cells, each cell line
88241 Thawing and expansion of frozen cells each aliquot
88245 Chrom.An-Break.Syn;25cls,Ct 5,1kary
88248 Chrom.An- Brk.Syn;100cls,Ct.20,2kary
88249 Chromosome analysis for breakage syndromes score 100 cells clastogen stress
88261 Chrom.Analy;ct.5 Cells,1 Kary,Band
88263 Chrom.Anal;ct.45 Clls-Mosaic,2 Kary
88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding
88269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6/12 colonies, 1 kayotype, with banding
88271 Molecular cytogenetics DNA probe each
88273 Molecular cypogenetics; chromosomal in situ hybridization, analyze 10-30 cells ( eg for microdeletions)
88275 Molecular cytogenetics interphase in situ hybridization analyze 100-300 cells
88280 Chromosomal analysis; additional karyotypes, each study
88291 Cytogenetics and molecular cytogenetics interpretation and report
91065 Breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro- cecal gastrointestinal transit)
91110 Gastrointestinal Tract Imaging, Intraluminal (Eg, Capsule Endoscopy), Esophagus Through Ileum, w Phys Interp and Report
91111 Gastrointestinal Tract Imaging, Intraluminal (Eg, Capsule Endoscopy), Esophagus with Physician Interpretation and Report
91112 Gastrointestinal Transit And Pressure Measurement, Stomach Through Colon, Wireless Capsule, W Interpretation And Report
92597 Evaluation for use of Voice Prosthetic
93228 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30 Days; Physician Review W Report
93229 Wearable Mobile Cardiovascular Telemetry with Events Transmitted To Center for up to 30 Days; Technical Support
93303 Transthoracic Echo cardiac anomalies
93304 Transthoracic Echo cardiac anomalies, limited
93306 Transthoracic Echo complete w color & spectral
93307 Transthoracic Echo complete wo color & spectral
93308 Transthoracic Echo limited
93312 Transesophageal Echo
93313 Transesophageal Echo probe only
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93314 Transesophageal Echo interpretation
93315 Transesophageal Echo congenital
93316 Transesophageal Echo congenital, probe only
93317 Transesophageal Echo congenital interpretation
93350 Transthoracic Stress Echo, complete
93351 Transthoracic Stress Echo, complete w cont EKG
93590 Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve
95805 Mult Sleep Latency;rec/Interp;mult
95807 Sleep Study, 3 or More Parameters Other Than Staging
95808 Polysomnography; Sleep Staging with 1 to 3 Additional Parameters
95810 Polysomnography; Sleep Staging with 4 or More Parameters
95811 Polysomnography; Sleep Staging With >3 Addit Parameters, W Cpap,Attend
95951 Monit/Lateraliz Seiz EEG & Video 24
95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
95974 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour
95975 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour (List separately in addition to code for primary procedure)
95978 Electronic Analysis Implanted Neurostimulator Pulse Generator System, Complex Deep Brain System, W Programming; First Hr
95979 Electronic Analysis Implanted Neurostim Pulse Generator System, Complex Deep Brain System, W Programming; Ea Addl 30 Min
96116 Neurobehavioral status exam, per hr psychologist/physician time, patient time and interpretation/report time
96118 Neuropsychological testing, per hr psychologist/physician time, patient time and interpretation/report time
96119 Neuropsych testing, qualified health care professional interp&report,admin by technician, per hr tech time, face- to-face
96120 Neuropsychological testing, administered by a computer, w qualified health care professional interpretation and report
97605 Negative Pressure Wound Therapy, Per Session; Total Area </= 50 Sq Cm
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guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
97606 Negative Pressure Wound Therapy, Per Session; Total Area > 50 Sq Cm
97607 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management colle
97608 Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management colle
99183 Physician Attendance and Supervision of Hyperbaric Oxygen Therapy; Per Session
A4290 Sacral nerve stimulation test lead, each
A7025 High Frequency Chest Wall Oscillation System Vest, Replacement For Use
A7026 High Frequency Chest Wall Oscillation System Hose, Replacement For Use
A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each
A9276 Disposable sensor, CGM sys
A9277 External transmitter, CGM
A9278 External receiver, CGM sys
C1767 Generator, neurostimulator (implantable), non-rechargeable
C1778 Lead, neurostimulator (implantable)
C1816 Receiver and/or transmitter, neurostimulator (implantable)
C1883 Adapter/extension, pacing lead or neurostimulator lead (implantable)
C1889 Implantable/insertable device for device intensive procedure, not otherwise classified
C2614 Probe, Percutaneous Lumbar Discectomy
C2616 Brachytherapy seed, yttrium-90
C2698 Brachytherapy source, stranded, not otherwise specified, per source
C2699 Brachytherapy source, non- stranded, not otherwise specified, per source
C9298 Injection, ocriplasmin, 0.125 mg
E0470 respiratory assis device, bi-level pressure capability, without back- up rate feature, used with non- invasive interface, eg, nasal or facial mask(intermittent assist device with continous positive airway pressure device
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with non- invasive interface, EG nasal or facial mask (intermittent assist device with continuous positive pressure device)
E0483 High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each
E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non- adjustable, custom fabricated,
E0601 Continuous positive airway pressure (CPAP) device
E0616 Implantable cardiac event recorder with memory, activator and programmer
E0617 External defibrillator with integrated electrocardiogram analysis
E0627 Seat lift mechanism incorporated into a combination lift-chair mechanism
E0629 Separate seat lift mechanism for use with patient owned furniture — non-electric
E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle
E0676 Intermittent limb compression device (includes all accessories), not otherwise specified
E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal applications
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E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications
E0749 Osteogenesis stimulator, electrical, surgically implanted
E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive
E0765 FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting
E0784 External ambulatory infusion pump, insulin
E0988 Manual Wheelchair Accessory, Lever-Activated, Wheel Drive, Pair
E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each
E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1801 SPS elbow device w/ or w/o range of motion adjustment, includes all components & accessories
E1802 Dynamic Adjustable Forearm Pronation/Supination Device, Inc Soft Inter
E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1806 SPS wrist device w/ or w/o range of motion adjustment, includes all components & accessories
E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material
E1811 SPS knee device w/ or w/o range of motion adjustment, includes all components and accessories
E1812 Dynamic knee, extension/flexion device with active resistance control
E1818 SPS forearm pronation/supination device w/ or w/o range of motion adjustment, includes all components & accessories
E1820 Replacement soft interface material, dynamic adjustable extension/flexion device
E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device
E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material
E2359 Power Wheelchair Accessory, Group 34 Sealed Lead Acid Battery, Each (E.G. Gel Cell, Absorbed Glassmat)
E2378 Pw actuator replacement
E2402 Negative pressure wound therapy electrical pump, stationary or portable
E2500 Speech generating device, digitized speech, using pre- recorded messages, 8 min. or less
E2502 Speech generating device, digitized speech, using pre- recorded messages, 8-20 min.
E2504 Speech generating device, digitized speech, using pre- recorded messages, 20-40 min.
E2506 Speech generating device, digitized speech, using pre- recorded messages, over 40 min.
E2508 Speech generating device, synthesized speech, requiring message formulation by spelling
E2510 Speech generating device, synthesized speech, permitting multiple methods
E2511 Speech generating software program, for personal computer or personal digital assistant
E2512 Accessory for speech generating device, mounting system
E2599 Accessory for speech generating device, not otherwise classified
E2622 Adj skin pro w/c cus wd<22in
E2623 Adj skin pro wc cus wd>=22in
E2624 Adj skin pro/pos cus<22in
E2625 Adj skin pro/pos wc cus>=22
G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minut
G0238 Therapeutic procedures to improve respiratory function , other than described by G0237, one on one, face to face, per
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G0239 Therapeutic procedures to improve respiratory function , other than services described by G0237, two or more (includes m
G0248 Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face- to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results
G0249 Provision Of Test Materials And Equipment For Home Inr Monitoring To P
G0250 Physician Review, Interpretation And Patient Management Of Home Inr Te
G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
G0341 Percutaneous islet celltrans
G0342 Laparoscopy islet cell trans
G0343 Laparotomy islet cell transp
G0424 Pulmonary rehab w exer
G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)
G0455 Fecal microbiota prep instil
G0500 Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)
G9143 Warfarin respon genetic test
G9708 Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy
G9748 Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant
G9750 Patient approved by a qualified transplant program and scheduled to receive a living donor kidney transplant
K0010 Stnd Wt Frame Power Whlchr
K0011 Stnd Wt Pwr Whlchr W Control
K0012 Ltwt Portbl Power Whlchr
K0013 Custom Power Whlchr Base
K0014 Other Power Whlchr Base
K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0743 Suction pump, home model, portable, for use on wounds
K0744 Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or less
K0745 Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 square inches
K0746 Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than
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48 square inches
K0800 Power operated vehicle,grp 1 standard,patient weight cap up to and incl 300 lbs
K0801 Power operated vehicle,grp 1 heavy duty,patient weight cap 301-450 lbs
K0802 Power operated vehicle, grp 1 very heavy duty,patient weight cap 451-600 lbs
K0806 Power operated vehicle, grp 2 standard,patient weight cap up to and incl 300 lbs
K0807 Power operated vehicle,grp 2 heavy duty,patient weight cap 301-450 lbs
K0808 Power operated vehicle,grp 2 very heavy duty,patient weight cap 451-600 lbs
K0812 Power operated vehicle,not otherwise classified
K0813 Power wheelchair,grp 1 standard,portable,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0814 Power wheelchair,grp 1 standard,portable,captains chair,patient weight cap up to and incl 300 lbs
K0815 Power wheelchair,grp 1 standard,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0816 Power wheelchair,grp 1 standard,captains chair,patient weight cap up to and incl 300 lbs
K0820 Power wheelchair,grp 2 standard,portable,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0821 Power wheelchair,grp 2 standard,portable,captains chair,patient weight cap up to and incl 300 lbs
K0822 Power wheelchair,grp 2 standard,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0823 Power wheelchair,grp 2 stnd,captains chair,patient weight cap up to and incl 300 lbs
K0824 Power wheelchair,grp 2 heavy duty,sling/solid seat/back,patient weight cap 301-450 lbs
K0825 Power wheelchair,grp 2 heavy duty,captains chair,patient weight cap 301-450 lbs
K0826 Power wheelchair,grp 2 very heavy duty,sling/solid seat/back,patient weight cap 451- 600 lbs
K0827 Power wheelchair,grp 2 very heavy duty,captains chair,patient weight cap 451-600 lbs
K0828 Power wheelchair,grp 2 extra heavy duty,sling/solid seat/back,patient weight cap 601 lbs or more
K0829 Power wheelchair,grp 2 extra heavy duty,captains chair,patient weight cap 601 lbs or more
K0835 Power wheelchair,grp 2 stnd,single power option,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0836 Power wheelchair,grp 2 stnd,single power option,captains chair,patient weight cap up to and incl 300 lbs
K0837 Power wheelchair,grp 2 heavy duty,single power option,sling/solid seat/back,patient weight cap 301- 450 lbs
K0838 Power wheelchair,grp 2 heavy duty,single power option,captains chair,patient weight cap 301-450 lbs
K0839 Power wheelchair,grp 2 very heavy duty,single power option,sling/solid seat/back,patient weight cap 451- 600 lbs
K0840 Power wheelchair,grp 2 extra heavy duty,single power option,sling/solid seat/back,patient weight cap up to and incl 300
K0841 Power wheelchair,grp 2 stnd,mult power option,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0842 Power wheelchair,grp 2 stnd,mult power option,captains chair,patient weight cap up to and incl 300 lbs
K0843 Power wheelchair,grp 2 heavy duty,mult power option,sling/solid seat/back,patient weight cap 301- 450 lbs
Prior Authorization List
32
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
K0848 Power wheelchair,grp 3 stnd,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0849 Power wheelchair,grp 3 stnd,captains chair,patient weight cap up to and incl 300 lbs
K0850 Power wheelchair,grp 3 heavy duty,sling/solid seat/back,patient weight cap 301-450 lbs
K0851 Power wheelchair,grp 3 heavy duty,captains chair,patient weight cap 301-450 lbs
K0852 Power wheelchair,grp 3 very heavy duty,sling/solid seat/back,patient weight cap 451- 600 lbs
K0853 Power wheelchair,grp 3 very heavy duty,captains chair,patient weight cap 451-600 lbs
K0854 Power wheelchair,grp 3 extra heavy duty,sling/solid seat/back,patient weight cap 601 lbs or more
K0855 Power wheelchair,grp 3 extra heavy duty,captains chair,patient weight cap 601 lbs or more
K0856 Power wheelchair,grp 3 stnd,single power option,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0857 Power wheelchair,grp 3 stnd,single power option,captains chair,patient weight cap up to and incl 300 lbs
K0858 Power wheelchair,grp 3 heavy duty,single power option,sling/solid seat/back,patient weight cap 301- 450 lbs
K0859 Power wheelchair,grp 3 heavy duty,single power option,captains chair,patient weight cap 301-450 lbs
K0860 Power wheelchair,grp 3 very heavy duty,single power option,sling/solid seat/back,patient weight cap 451- 600 lbs
K0861 Power wheelchair,grp 3 stnd,mult power option,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0862 Power wheelchair,grp 3 heavy duty,mult power option,sling/solid seat/back,patient weight cap 301- 450 lbs
K0863 Power wheelchair,grp 3 very heavy duty,mult power option,sling/solid seat/back,patient weight cap 451- 600 lbs
K0864 Power wheelchair,grp 3 extra heavy duty,mult power option,sling/solid seat/back,patient weight cap 601 lbs or more
K0868 Power wheelchair,grp 4 stnd,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0869 Power wheelchair,grp 4 stnd,captains chair,patient weight cap up to and incl 300 lbs
K0870 Power wheelchair,grp 4 heavy duty,sling/solid seat/back,patient weight cap 301-450 lbs
K0871 Power wheelchair,grp 4 very heavy duty,sling/solid seat/back,patient weight cap 451- 600 lbs
K0877 Power wheelchair,grp 4 stnd,single power option,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0878 Power wheelchair,grp 4 stnd,single power option,captains chair,patient weight cap up to and incl 300 lbs
K0879 Power wheelchair,grp 4 heavy duty,single power option,sling/solid seat/back, patient weight cap 301-450 lbs
K0880 Power wheelchair,grp 4 very heavy duty,single power option,sling/solid seat/back,patient weight 451-600 lbs
K0884 Power wheelchair,grp 4 stnd,mult power potion,sling/solid seat/back,patient weight cap up to and incl 300 lbs
K0885 Power wheelchair,grp 4 stnd,mult power option,captains chair,weight cap up to and incl 300 lbs
K0886 Power wheelchair,grp 4 heavy duty,mult power option,sling/solid seat/back,patent weight cap 301-
Prior Authorization List
33
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
450 lbs
K0890 Power wheelchair,grp 5 ped,single power option,sling/solid seat/back,patient weight cap up to and incl 125 lbs
K0891 Power wheelchair,grp 5 pediatric,mult power option,sling/solid seat/back,patient weight cap up to and incl 125 lbs
K0898 Power wheelchair,not otherwise classified
K0899 Power mobility device, not coded by DME PDAC or does not meet criteria
L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence system
L5613 Addition to lower extremity, endoskeletal system, above knee — knee disarticulation, 4 bar linkage, with hydraulic swing
L5614 Addition to lower extremity, endoskeletal system, above knee — knee disarticulation, 4 bar linkage, with pneumatic swing
L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control
L5724 Addition, exoskeletal knee-shin system, single axis, fluid swing phase control
L5726 Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control
L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control
L5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control
L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock
L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock
L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control
L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control
L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame
L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control
L5840 Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase control
L5848 Addition to endoskeletal knee- shin system, fluid stance extension, dampening feature, with or without adjustability
L5856 Addition to lower extremity prosthesis, endoskeletal knee- shin system, microprocessor control feature, swing and stance
L5857 Addition to lower extremity prosthesis, endoskeletal knee- shin system, microprocessor control feature, swing phase only,
L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only
L5859 Knee-shin pro flex/ext cont
L5961 Endo poly hip, pneu/hyd/rot
L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source
L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s
Prior Authorization List
34
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
L6628 Upper extremity addition, quick disconnect hook adapter, otto bock or equal
L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal
L6632 Upper extremity addition, latex suspension sleeve, each
L6680 Upper extremity addition, test socket, wrist disarticulation or below elbow
L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation
L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement
L6810 Addition to terminal device, precision pinch device
L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)
L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device
L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device
L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment
L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6935 Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
L7007 Electric hand, switch or myoelectric controlled, adult
L7008 Electric hand, switch or myoelectric, controlled, pediatric
L7009 Electric hand, switch or myoelectric, controlled, pediatric
L7045 Electric hook, switch or myoelectric controlled, pediatric
L7180 Electronic elbow, microprocessor sequential control of elbow and terminal device
L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device
L7190 Electronic elbow, adolescent, variety village or equal, myoelectronically controlled
L7191 Electronic elbow, child, variety village or equal, myoelectronically controlled
L7368 Lithium ion battery charger, replacement only
L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)
L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
L8465 Prosthetic shrinker, upper limb, each
Prior Authorization List
35
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
L8614 Cochlear device, includes all internal and external components
L8615 Headset/headpiece for use with cochlear implant device, replacement
L8616 Microphone for use with cochlear implant device, replacement
L8617 Transmitting coil for use with cochlear implant device, replacement
L8618 Transmitter cable for use with cochlear implant device, replacement
L8619 Cochlear implant, external speech processor and controller, integrated system, replacement
L8621 Zinc air battery for use w/ cochlear implant device, replacement, each
L8622 Alkaline battery for use w/ cochlear implant device, any size, replacement
L8627 Cochlear implant, external speech processor, component, replacement
L8628 Cochlear implant, external controller component, replacement
L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
L8679 Implantable neurostimulator, pulse generator, any type
L8680 Implantable neurostimulator electrode, each
L8681 Pt prgrm for implt neurostim
L8682 Implt neurostim radiofq rec
L8683 Radiofq trsmtr for implt neu
L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
L8685 Implt nrostm pls gen sng rec
L8686 Implt nrostm pls gen sng non
L8687 Implt nrostm pls gen dua rec
L8688 Implt nrostm pls gen dua non
L8689 External recharging system
L8690 Auditory osseointegrated device, includes all internal and external components
L8695 External recharg sys extern
M0300 Iv Chelationtherapy
Q0478 Power adapter, combo vad
Q0506 Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0507 Misc supply or accessory for use with an external ventricular assist device
Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device
Q0509 Misc supply or accessory for use with any implanted ventricular assist device for which pymt was not made under Medicare Part A
Q2026 Radiesse Injection
Q2028 Sculptra Injection
Q4101 Skin substitute, Apligraf, per square centimeter
Q4102 Skin substitute, Oasis Wound Matrix, per square centimeter
Q4105 Skin substitute, Integra Dermal Regeneration Template (DRT), per square centimeter
Q4106 Skin substitute, Dermagraft, per square centimeter
Q4107 Skin substitute, Graftjacket, per square centimeter
Q4110 Skin substitute, Primatrix, per square centimeter
Q4114 Integra flowable wound matrix, injectable, 1 cc
Prior Authorization List
36
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
Q4121 Theraskin
Q4124 Oasis ultra tri-layer wound matrix, per square centimeter
Q4131 Epifix
Q4166 Cytal, per square centimeter
Q4167 Truskin, per square centimeter
Q4168 Amnioband, 1 mg
Q4169 Artacent wound, per square centimeter
Q4170 Cygnus, per square centimeter
Q4171 Interfyl, 1 mg
Q4172 Puraply or puraply am, per square centimeter
Q4173 Palingen or palingen xplus, per square centimeter
Q4174 Palingen or promatrx, 0.36 mg per 0.25 cc
Q4175 Miroderm, per square centimeter
S0317 disease management program; per diem
S1040 Cranial Remodeling Orthosis, Rigid W/Soft Interface Material
S2340 Chemodenervation Of Abductor
S2341 Chemodenervation of adductor muscle(s) of vocal cord
S9473 Pulmonary Rehabilitation Pro
93454** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation
93455** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intra procedural injection(s) for bypass graft angiography
93456** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with right heart catheterization
93457** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intra procedural injection(s) for bypass graft angiography and right heart catheterization
93458** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with left heart catheterization including intra procedural injection(s) for left ventriculography, when performed
93459** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with left heart
catheterization including intra procedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) with bypass
graft angiography
93460** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with right and left heart catheterization including intra procedural injection(s) for left ventriculography, when performed
Prior Authorization List
37
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
93461** Catheter placement in coronary artery(s) for coronary angiography, including intra procedural injection(s) for coronary angiography, imaging supervision and interpretation with right and left heart catheterization including intra procedural injection(s) for left ventriculography, when performed catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) with bypass graft angiography
93452** Left heart catheterization including intra procedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed
27130 Arthroplasty, acetabular, proximal femoral prosthetic replacement(total Hip arthroplasty), with or without autograft or allograft
27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft
27446 Arthroplasty, knee, condyle and plateau, medial or lateral compartment
27447 Arthroplasty, knee medical and lateral compartments with or without patella resurfacing(total knee arthroplasty)
23470 Arthroplasty, glenohumeral joint, hemiarthroplasty
23472 Arthroplasty, total shoulder
**Cardiac Procedure Code processed by AIM Specialty Health J2504 Adagen†
J1931 Aldurazyme†
J9034 Bendeka†
J0585 Botox
J1786 Cerezyme†
J2786 Cinqair
J9308 Cyramza
J9145 Darzalex
J0586 Dysport
J1743 Elaprase
J3060 Elelyso
J9176 Empliciti
J3490 Exondys 51
J0178 Eylea
J0180 Fabrazyme†
J9325 Imlygic
J7316 Jetrea
J2840 Kanuma
J9271 Keytruda†
J9047 Kyprolis
J9999 Lartruvo
J2778 Lucentis
J0221 Lumizyme†
Prior Authorization List
38
On behalf of Premera Blue Cross, Visiant provides prior authorization services. Prior authorization is not a
guarantee of payment. Benefits are based on eligibility at the time of service and are subject to applicable
contract terms.
J2503 Macugen
J0587 Myobloc
J1458 Naglazyme†
J2182 Nucala
J9025 Onivyde
J9299 Opdivo
J0570 Probuphine
J9295 Portrazza
J1322 Vimizim
J3385 VPRIV
J0588 Xeomin
J2357 Xolair†
J9228 Yervoy†
J9352 Yondelis
J1556 Bivigam†
J1566 Carimune†
J3590 Cuvitru†
J1572 Flebogamma†
J1569 Gammagard†
J1566 Gammagard S/D†
J1561 Gammaked†
J1557 Gammaplex†
J1561 Gamunex-C†
J1575 HyQvia†
J1568 Octagam†
J1459 Privigen†
J7320 Genvisc†
J7321 Hyalgan, Supartz†
J7322 Hymovis†
J7323 Euflexxa†
J7324 Orthovisc†
J7325 Synvisc or Synvisc-One†
J7326 Gel-one†
J7327 Monovisc†
J7328 Gel-Syn†
J7330 Carticel† † Drug has prior authorization overlap with the Part D formulary